Electronic orders a stumbling block for pathology on PCEHR

The low level of electronic ordering of pathology tests has emerged as a major stumbling block to progress in developing a workable method for uploading pathology reports to the PCEHR.

Progress has been made on a high-level solution design following a series of Department of Health-hosted workshops last year, including one held in Melbourne in late November.

A new section for pathology and diagnostic imaging reports has also been added to the consumer view of the system following the release of version five of the PCEHR on December 1.

However, there are outstanding issues concerning how to transfer healthcare identifiers with the pathology request, what modifications the private and public pathology sectors will have to make to their software, and whether any recompense for those modifications will be forthcoming.

Agreement has been reached that the pathology provider will upload the full report as a PDF, which will be immediately viewable by registered healthcare providers but will not be open to the patient for seven days.

Discussions are continuing on how to ensure sensitive results are not uploaded, what to do when a patient withdraws consent and what to do in exceptional circumstances such as those affecting mature minors whose parents are still in control of the record.

However, the practical implications for private pathology providers, GPs and specialists are also becoming more clear, with a particular concern over the low level of electronic ordering from GPs – and the almost non-existent level from specialists – emerging as a major issue.

Pathologist Lawrie Bott, CEO of Sonic Healthcare subsidiaries Hobart Pathology and Southern IML Pathology, who has represented peak body Pathology Australia on a number of eHealth committees, said there is still only a very low level of tests requested electronically, a situation that will need to be resolved before any progress is made.

“There is a lot of work to be done,” Dr Bott said. “At the moment most [requesting] is straight paper. The biggest electronic ordering lab is my lab here in Tasmania. We are probably getting 80 per cent of all our GP work through electronic systems, which is all we can get as specialists tend not to have compatible systems.”

Tasmania is an outlier, however. Dr Bott said that as far as he was aware, there was a moderate level of electronic ordering in Queensland through another Sonic subsidiary, Sullivan Nicolaides Pathology, but in most other states the levels were very low.

He could not comment on the levels of electronic ordering in Healthscope or Primary Health Care pathology labs, but understands it too is very low.

An electronic system is essential in order to ensure the patient's individual healthcare identifier (IHI) is recorded with the request, but Dr Bott does not hold out much hope that this will happen quickly.

“The government is pushing for an electronic system and the reason they are is because electronic requesting is at such a low level,” he said. “They know that. But the reason why electronic requesting is at such a low level is that the clinical doctors at this point in time don't see a value proposition in it.”

In the meantime, no pathology provider is going to take the time to type the patient's IHI into their systems from a paper request, which is a dangerous practice anyway. The alternative is to barcode pathology requests, similar to prescriptions, but Dr Bott said there are too many problems with the consistency and quality of barcodes.

“[The IHI] is a 16-digit number and that can't be typed in. In Australia for Sonic Healthcare, you are probably talking about 60,000 patient episodes a day. In the whole private area you are looking at probably 150,000 episodes a day, and I don't even know what it is in the public system but in total it must be approaching a quarter of a million patient episodes a day.

“We aren't going to be typing in 250,000 16-digit numbers. The workload would be massive and the error rate would be dangerous. We have presented to the department that this is untenable and it has to be an electronic system to operate.”

Few private pathology providers are registered as yet with the HI Service, but more importantly little work has been done in planning for the use of the service in the sector. Dr Bott said Sonic had done some early trials using healthcare identifiers but has not done much work recently as there was no agreed design to work from.

In the private pathology sector's favour is that most of the internal IT systems are bespoke or owned by the provider rather than third-party vendors. Sonic, for example, uses software based on the old Detente system that has since been developed internally, while Healthscope and Primary use systems first developed in the 1980s and 1990s by Australian company Triple G, were then sold to GE and which the providers now own.

Dr Bott said owning the software would make the modifications easier, but there was still a lot of work to be done, and the public sector, which predominantly does use third-party software, will face major challenges.

“I think that's one of the huge advantages that the private area has over the public area in that we can control our IT development,” he said. “I think there will be a big problem with public labs where they are not in control of their IT. They will need significant areas of development done.”

Another stumbling block is remuneration. While some GP and aged care software vendors were compensated for work done in the early stages of the PCEHR, there is no hint that the pathology or the diagnostic imaging sector will be similarly remunerated.

This is of major concern to Pathology Australia. Its new president, Nick Musgrave, said that both the industry body and the Royal College of Pathologists of Australasia (RCPA) had long been involved in the development of eHealth and were keen to see the PCEHR come to fruition, but what has been a problem to date is resourcing.

“It involves an expenditure on the part of providers and we've been keen to work with the government on trying to get the resources needed to do the software development,” Dr Musgrave said.

“That is an active issue as it is going to be a pretty expensive outlay. It will require a certain amount of time and effort for our members. We are supporters of and see benefits to end users but the point that we would like to get across to government is that while we want to assist in the process of implementation, we need support. We can't underwrite the process ourselves.”

From the general practice perspective, there are also some issues that need to be resolved. Both Dr Bott and RACGP representative Nathan Pinskier said work need to be done on a consent message or flag and how that is transmitted to the pathologist, but also what to do in exceptional cases.

“There may be a legitimate reason why a result should not get posted,” Dr Pinskier said. “It may be a small percentage, but there should be a mechanism by which the laboratory, in conjunction with the requester, can further delay the upload to the PCEHR.”

For Dr Pinskier, there is an obvious problem when it comes to minors, such as children under 14 who are not the legal custodians of their PCEHR, and children between 14 and 18 who have not yet assumed control of their PCEHR.

“For example, a girl in either of these categories might have a highly sensitive test such as a pregnancy test,” he said. “As her parents are in control of her PCEHR, they will be able to see the result, something which the child might not be aware of.

“The PCEHR has already made partial provision for this scenario in that no Medicare data is posted to a child’s PCEHR after the age of 14 until they take control of their record. A similar principle needs to be considered for diagnostic results.”

There are also cases of errors, rare as they, such as the contamination of batches of results. “There are significant concerns with automatic posting,” Dr Pinskier said. “If you automatically post, and then you pick up an error, you need an ability to stop it being displayed. The problem is, now it’s not an [authority to post] flag but a consent flag, so what power does the author or requester have to change the consent of the consumer?”

Dr Bott said that both disciplines agreed that there had to be some sort of consent message. “[Pathologists] want to be told that we have been given permission to load this result to the PCEHR,” he said. “It could be given at the beginning at the point of request, where the GP and the patient agreed that it should be uploaded.

“What the GPs want is in many cases to be able to clinically curate the result. They want to have a look at the result, possibly have a conversation with the patient about it and then at that point put it up. But to do that in any system you need a consent message. We need a consent message and we need attached to that the IHI, otherwise it's a dangerous system.”

Comments

Its too late to ask, but why pdf? A clinician would then have to open multiple pdfs to see an HbA1c trend? In rural towns patients flip flop from public to private pathology, so a cumualtive view of results is impossible.

Its too late to ask, but why pdf? A clinician would then have to open multiple pdfs to see an HbA1c trend? In rural towns patients flip flop from public to private pathology, so a cumualtive view of results is impossible.

There are a couple of reasons that are covered in this story from last year, PPP. The RCPA was very concerned that results would not make sense without the full pathologist's report, and moreover would be unsafe.